A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Activity intolerance.

Fluid volume excess.

Ineffective airway clearance.

Altered nutrition; less than body requirements.

Answer and Explanation

The Correct Answer is C

Choice A reason: Activity intolerance is important but not the highest priority immediately after surgery.

Choice B reason: Fluid volume excess can be a concern but is not as critical as ensuring effective airway clearance.

Choice C reason: Ineffective airway clearance is the highest priority as it directly impacts the client’s ability to breathe and maintain adequate oxygenation, which is crucial for postoperative recovery.

Choice D reason: Altered nutrition is also important but is not the immediate priority compared to airway clearance.

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Correct Answer is A

Explanation

Choice A reason: Completing ongoing focused assessments, particularly for a client with wrist restraints, requires the clinical judgment and skills of an RN.

Choice B reason: Supervising a newly hired graduate nurse is important but can also be done by the charge nurse or another experienced RN.

Choice C reason: Transporting a client to the radiology department can be done by a UAP or PN.

Choice D reason: Administering PRN oral analgesics can be delegated to a PN.

A. Continue with the blood pressure assessment. B. Note the presence of an auscultatory gap. C. Reposition the stethoscope over the brachial artery. D. Reinflate the cuff to a higher number.

Correct Answer is B

Explanation

Choice A reason: Continuing with the blood pressure assessment without acknowledging the auscultatory gap may result in an inaccurate reading.

Choice B reason: Noting the presence of an auscultatory gap is important as it indicates a brief period when Korotkoff sounds disappear and then reappear, which can lead to underestimation of systolic blood pressure and overestimation of diastolic blood pressure if not recognized.

Choice C reason: Repositioning the stethoscope may not address the issue of the auscultatory gap and may lead to inaccurate readings.

Choice D reason: Re-inflating the cuff to a higher number is unnecessary and may cause discomfort without addressing the auscultatory gap.

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A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Correct Answer is A

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is B

Explanation

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